documentation of fluid balance of patients on intravenous

Documentation of Fluid Balance of Patients on Intravenous Therapy in a University Hospital in Ghana

Susanna Aba Abraham, MPH,BA,RNGifty Osei Berchie, MSc, BA, RNChristiana Okantey, MPhil, BA, RNVida Maame Kissiwaa Amoah, MSc, BA, RNKweku Agyei-Ayensu, BSN, RN

Faculty DisclosureFaculty Name Susanna Aba Abraham MPH,BA,

RN

Conflict of Interest None

Employer University of Cape Coast, Ghana

Sponsorship/commercial Support None

Faculty Name Gifty Osei Berchie MSc, BA, RN


Employer University of Cape Coast


Faculty Disclosure cont’d.Faculty Name Christiana Okantey, MPhil, BA, RN


Employer University of Cape Coast


Faculty Name Vida Maame Kissiwaa Amoah, MSc, BA, RN


Employer Garden City University College, Kumasi, Ghana


Faculty Disclosure cont’d.Faculty Name Kweku Agyei-Ayensu, BSN, RN


Employer Ghana Health Service


Goals and Objectives Session goals:◦ Promoting Health in Clinical Setting

Objectives:◦ Participants will be acquainted with Intravenous

Fluid (IVF) documentation practices of nurses in a University Hospital in Ghana.◦ Participants will be exposed to factors influencing

IVF documentation in a University Hospital in Ghana.

Introduction

Fluid makes up about 60percent of the total body weight (White, 1998).

In healthy patients, ingestion of fluids of all kinds contributes to maintaining fluid balance.

But in some patients, Intravenous (IV) therapy can be a lifesaver.

Hospitalized patients need IV fluids and electrolytes for one or more of the following reasons: ◦ fluid resuscitation, ◦ routine maintenance, ◦ replacement and ◦ fluid redistribution

However, there are potential dangers associated with inappropriate IVF administration.

20% of patients on IVF therapy may experience a complication as a result of too much, too little or the wrong type of the fluid (National Confidential Enquiry into peri-operative Deaths, 1999).

◦ Asymptomatic: decrease in lung mechanics and gas exchange (Holte et al, 2003), ◦ Severe or permanent neurological

dysfunction (Schrier, 2008).◦ Some complications prove fatal (Nathan,

2007).

Post-operative over-hydration occurs in 17-54% of patients [noted to increase morbidity and prolong hospital stay].

Up-to 50% of patients especially the elderly develop at least one fluid-related complication due to post-operative over-hydration (National Institute of Health and Care Excellence, 2013).

IVF administration is also reported to contribute to about 9000 deaths annually in the USA (National Institute of Health and Care Excellence, 2013).

Not much information is reported on complications associated with IVF administration in Sub-Saharan Africa and Ghana specifically.

• Nurses have a responsibility in IV therapy administration (Claywell, 2014) including ensuring◦ the correct fluid is administered.◦ the rate of flow of the fluid is correct◦ monitoring the patient during fluid

administration ◦ the procedure and any effects associated

with the process are documented (Holte, Jensen & Kehlet, 2003)

• However these are often not given the necessary attention during infusion therapy

Problem statement Nurses’ records of fluid balance and certain

laboratory reports are essential to determine the required fluid intake levels of a client (Western Health and Social Care Trust, 2010).

However, studies have reported failures in nursing observations, in particular inadequate and inaccurate charting (Jeyapala, Gerth, Patel, & Syed, 2015).

In addition, studies on fluid charting in Ghana is none existent.

The study therefore sought to examine nurses’ documentation of IV therapy and to identify factors that influence their practices.

MethodsDesign and Setting Exploratory cross-sectional study.◦ Prospective audit of intake and output records of

patients on admission.◦ Semi structured individual interviews with nurses

. The study was conducted at a University

hospital in Ghana. ◦ It provides primary care for university staff and

residents in the nearby communities.◦ Serves as a clinical training site for; BSc nursing students. House officers.

Sampling Patient records:◦ Inspected patients’ folders for those

prescribed with intravenous fluids◦ A list was compiled of patients who had

received a prescription for 24 hours or more and had received at least the first dose.◦ Sampling was done for one month◦ A total of eighty-two patients were recruited

from four wards (Male, Female, Pediatric/NICU and Maternity).

Sampling –cont’d.

• Nurses: ◦ Purposive sampling of six nurses. ◦ Ward in-charges and registered nurses ◦ They should have worked in the hospital for

at least one year.

Data collection Patients record◦ Prospective audit of intake and output charts

for one month using a designed checklist.◦ Sought to document completeness of records:

patients’ particulars Date and time of administration Type of fluids Amounts of fluids Characteristics of fluids 24 hours fluid balance Comments of observations Signature of administering nurse

Nurses:◦ Individual interviews were conducted using semi

structured open-ended questions, that ensured participants freely shared their opinion of factors influencing their IV documentation practices.

◦ This method provided rich data from the participants (Creswell, 2012).

◦ Interviews were conducted in English and lasted between 30-45 minutes

◦ All the interviews were audio recorded and transcribed verbatim

Ethical Approval KNUST Committee on Human Research

Publications and Ethics, School of Medical Sciences gave ethics approval for the study

KNUST hospital management gave approval for accessing their records and contacting the nurses.

Written and oral consent from the nurses who were enrolled in the study after a detailed information on the study had been given.

Data Analysis Records Audit: Documentation Practices on

intake and output chart◦ SPSS version 20: Univariate and bivariate analysis

Nurses’ interviews: Factors influencing documentation practices.◦ Verbatim transcription of data was done. ◦ Content analysis. The main questions constituted

the categories.

Findings: Completeness of patients’ intake and output chart.

Association b/n patients’ demographics and nurses’ documentation practices

Association b/n patients’ demographics & nurses’ charting of output characteristics

Qualitative data collection

Nurses interviews: Six participants: Five females and one male

aged 24-46 years Years of nursing experience ranged from

two years to twelve years.

All the participants agreed that documentation of IVF was essential.

A number of participants suggested that it was as essential as administering the fluid itself

“In nursing it is said that if it is not written, then it was not done… so documenting that

you gave the fluid is as important as administering it…” (P 4).

Findings: Importance of IVF documentation

All the participants reported that the nurse must document on the intake and output chart but only one (P 2) suggested that abnormal findings should be reported to the nurse manager.

◦ The nurse is responsible for ensuring that intake and output charts are recorded as often as a new bag is

administered” (P 4).

◦ It is not just writing but when you balance and the output is more than the input you have to report to the nurse in-

charge)” (P 2).

Findings:Importance of IVF documentation

Safe practiceA number of the nurses suggested that

charting intake and output reduces the risk of complications.

“You see, the house officers usually prescribe the fluids and they are not really experienced so if we are not careful, we will over hydrate the patients, so filling the chart

and checking it will prevent that”. (P 1)

Findings:Importance of IVF documentation

Evidence of care deliverySome nurses opined that charting the

patients’ intake and output shows that the nurse performed the procedure and worked during the shift.

“ When you chart, it is evidence that you actually gave the fluid or even gave the right dose, so you are protected in case something

happens” (P 2)

Importance of IVF documentation Continuity of careMost of the participants suggested that the

chart was essential in ensuring that care provided was quality across all the shifts.

◦ “ … the nurses who take over from us can refer to it after we have left for home to ensure that they provide the right care without necessarily

calling us”. (P 5)

Factors affecting IVF documentation

Several factors were cited as affecting IVF documentation:◦ Workload during a shift, ◦ Delegation and supervision of IVF

responsibilities, ◦ Condition of the patient, ◦ Design of the Intake and Output chart◦ The size of the chart.

Workload The nurses asserted that the volume of work

during a shift affected IVF documentation.

◦ “Sometimes when you come on duty, the ward is full and there is so much to be done, so if you decide to

delay the charting small, you may forget” (P 4).

◦ “There are so many things to document alongside the nursing work. So sometimes we choose to rather do

the work rather than to sit and write” (P 6).


Supervision of delegated careThe participants reported that supervision

of delegated IVF responsibilities influenced documentation.

◦ “due to shortage of RNs and increased workload, sometimes the responsibility of mounting a new bag of fluid is delegated to nurse assistants and if you don’t follow up to ensure that they charted, they sometimes forget to chart which may lead to incomplete or non documentation”. (P 5)


Condition of the patientAll the nurses reported that the condition of

the patient receiving IVF was a major reason for documenting.

◦ “You know that patient’s with kidney problems need to be strictly monitored. So as for that one, we consciously

monitor it” (P 3).

◦ “If the patient has a condition that requires strict monitoring of the intake and output we make sure we adhere strictly to that. This is because the patient may

be in danger if we don’t monitor it” (P 6).


Design of the intake and output chartSome nurses asserted that the columns

provided on the intake and output chart do not include portions for signature and 24-hour balancing resulting in incomplete documentation.

◦ “ the way the chart is designed, it does not provide any column for signing even our initials, so we take it for granted”. (P 4)

◦ “There is no column for balancing at the end of the day.” (P 3)


The size of the sheet “ this sheet is too small. It is sometimes so difficult to document especially in the output

section. For those of us with big handwriting, it makes it so clumsy”. (P 1)


Implications of not documenting IVF administration

Legal implicationsSome nurses were not aware of the

possibility of infusion therapy litigation. A participant responded:

“I have not heard of court case because of IVF documentation but I know that nurses’

notes are tenderable in court” (P 6).

Discussion

All the nurses knew that documentation of IVF administered to patients was an essential practice. This concurs with a study by Vicdan, (2014).

Incidents of incomplete or non documentation of the IVF administered in the intake and output chart were recorded. This is supported by a finidings study by Ling, Ling, Chin, Wong, et al, (2011).

Discussion Incomplete documentation of output was

high in this study.

24-hour balancing of fluid intake and output was omitted in most of the patients’ records. This is consistent with findings of a study by Walker, Stewart-Parker, Chinthapalli, Ostermann, Dargan, Wood, (2012).

Discussion Workload, design of the intake and output

chart and the space to document were identified as factors that negatively affected documentation of IVF administered. A similar finding was revealed by (Aslam et al, 2017; Diacon, 2012).

Conclusion There is incomplete and non documentation

of intake and output for patients on intravenous therapy.

Nurses do not document the output and the 24-hour balance of the patients on IVF.

Nurses are however aware that recording intake and output for patients’ on IVF is essential.

Recommendation Redesign the intake and output chart to

include columns for 24-hour balance and signature of the nurse.

In-service training on IV fluid therapy documentation.

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Reference cont’d.

documentation of fluid balance of patients on intravenous

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